Pharmacotherapuetics Exam 1 ( Intro to ID, Pharmackinetics, Pneumonia/Influenza, Endocarditis/Bactermia, Osteomyelitis, Septic Arthritis & UTI + core calculation)

What are pre-disposing factors of UTI?

1. Female Gender 2. Sexual activity / new sexual partner 3. Use of spermicides and diaphragms 4. Urinary tract obstruction such as stone /tumor 5. DM 6. History of cystitis 7. Family History of UTI in first-degree family relative

What is the main etiology of uncomplicated UTI?

Escherichia Coli (75-90%)

What are some other etiologies of uncomplicated UTI?

1. Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus saprophyticus

What is the main etiology of complicated UTI?

Escherichia coli ( Less than 50%)

What are some other etiologies of complicated UTI?

Protus spp. K. penumoniae, Enterobacter spp., P. aeruginosa, Staphylococci, and Enterococci

What is the etiology of short term catheters related UTI?

E. coli <30%

What is the etiology of long term catheters related to UTI?

usually polymicrobial (E. coli, P. Mirabilis, Morganella morganii, P. stuartii)

What are the ways you can diagonsis an UTI in a patient?

1. Clincial presentation 2. Dipstick test (outpatient), 3. Urinalysis 4. Urine culure and sensitivity

True or False : It is always necessary for a urinalysis and or urine culture to be done to check for an UTI?

False

How can a presumptive diagonsis of a UTI be made in a symptomatic female patient if what?

1. dysuria and frequency of urination who is not experiencing any vaginal symptoms OR

2. a postive Nitrite or leukocyte esterase dipstick test

What is a midsterm clean catch urine collection?

urinating into a sterile collection cup. Clean urethral opening, 20 to 30 mls is voided and discarded, urine is collected

What is a catheterization urine collection?

for uncooperative patients or those unable to void - this may cause introduction of bacteria into the bladder

What is a suprapubic aspiration urine collection?

inseration of a needle directly into the bladder and removing urine - useful for newborns, infants, paraplegics and seriously ill patient - contamination highly unlikely with this method

What are indicators for UTI on the urinalysis?

1. WBC (pyuria) 2. Hematuria 3. Proteinuria 4. Nitrities 5. Leukocyte esterase

What is uncomplicated UTI?

Infection confined to the bladder in afebrile women or men

What is complicated UTI?

1. Infections occuring in women or men

2. Pyelonephritis (CVA tenderness " flank pain")

3. Febrile or bacteremic UTI (fever, chills, hemodynamic instability)

4. Cathether associated UTI (CAUTI)

What are clincial presentation of lower UTI (cystitis) ?

1. Burning on urination (dysuria)

2. Frequent urination (polyuria)

3. Urgency to urinate

4. Suprapubic pain / heaviness

5. Back pain

6. Urinating at night (nocturia)

7. WBC in urine (pyuria)

8. RBC in urine (hematuria)

What are clinical presentation of Upper UTI (pyelonephritis)?

1. Fever

2. Chills

3. Costovertebral angle (CVA) tenderness

4. Nausea / Vomiting

What are nonpharmacologic or ajunct therapy?

1. Avoid "avoidable" predisposing factors (spermicide, sexual activity)

2. Postcoital urination may help flush out any bacteria that may have been introduced during sexual activity

3. Do not ignore the urge to void - urine rentention increases risk of UTI

4. Increased fluid intake may help flush out bacteria present

5. Cranberry juice / capsules / extract may help reduce the risk of recurrent UTI

What medication can be reduce the risk of recurrent infections in those 12 years of and older?

Methenamine Hippurate

What medication can be given to a patient for pain releif and may provide acue relief of symptoms - dysuria, frequency and urgency to urinate?

phenazopyridine

What are the directions of phenazopyridine?

200mg orally 3 times daily for maximum of 2 days (take after meals)

What are the contrindications for the use of phenazopyridine?

patients with renal disease or severe hepattis

What is the medication options for treatment of uncomplicated cystitis (UTI)

1. Nitrofurantoin 100mg by mouth twice daily for 5 days

2. Fosfomycin trometramol 3g orally in single dose

3. Trimethoprim-sulfamethoxazole (TMP/SMX) 160/800mg 1 double strength (DS) tablet orally twice daily for 3 days (7-10 days for complicated cystitis)

What are second line treatment for uncomplicated cystitis (UTI)?

1. Fluroquinolones (3 days for uncomplicated cystitis)

2. Beta-lactams 3-7 days for uncomplicated cystitis

- Amox/clavulanate 3-7 days

- Ceftriaxone 7 days

- Cefdinir 7 days

- Cefaclor 7 days

- Cefpodoxime 7 days

* Beta-factams are not as efficacious as first line agents *

What is the treatment for complicated cystitis without sepsis? (Oral Options)

1. ciprofloxacin 500mg orally twice daily 7 days

2. levofloxacin 500mg or 750mg orally daily for 5 days

3. Bactrim - 800mg/160mg orally every 12 hours 7 days

What organism is the most common cause of community-aquired pneumonia (CAP)

Streptococcus pneumoniae

What are considered an atypical organism causing CAP?

1. Mycoplasama pneumoniae 2. Haemophilus influenzae 3. Chlamydia pneumoniae

Pneumonia developing > 48 hours after intubation and mechanical ventilation is considered?

Ventilator associated (VAP)

Pneumonia developing >48 hours after hospital admission is considered?

Hospital-acquired (HAP)

Pneumonia developing in patients with no contact to a medical facility

Community Acquired Pneumonia (CAP)

What patient should have a sputum culture performed?

1. Patients with severe CAP

2. all inpatients empirically treated for or recent history of MRSA or P. aeruginosa in the resp. tract

3. pts that have been recently hospitalized or who have been treated with antibiotics in the past 90 days

4. pts not responding to inital therapy

What are benefits of urinary antigen tests?

1. Useful for pts who cannot provide sputum for a fputum culture (urine is easier to obtain)

2. Useful for pts who have received antibiotics as the atigen will remain in the urine for up to 3 days afte abx initiation

What are non-pharmacologic therapy for pneumonia for management?

1. Hydration

2. Mechanical ventilation (if necessary)

3. Chest physiotherapy

4. Humidified oxygen

What is the treatment for outpatient emperic of CAP (no comorbidies and no risk factors for MRSA or P. aergionosa)

1. Amox 1g PO TID

2. Doxy 100mg PO BID (if local resistance is <25%)

3. Macrolide (if local resistance is <25%) azithromycin 500mg PO on day 1 followed by 250mg PO x 4 days or clarithromycin ER 1000mg daily or clarithromycin 500mg PO BID

What are co-morbidities of CAP?

1. chronic heart disease

2. lung disease

3. liver disease

4. renal disease

5. DM

6. alcoholism

7. malignancies

8. asplenia

If a patient has a co-morbidity how would would treat outpatient empiric CAP?

1. Beta-lactam + a macrolide or a beta-lactam + doxycycline OR use respiratory fluoroquinolone monotherapy

What is the antibiotic option for patients with comoribidies?

1. Combination of amoxicillin / clavulanate 500/125mg PO TID (875/125mg PO BID or 2000/125mg PO BID) OR a cephalosporin (cefpodoxime 200mg PO BID or cefuroxime 500mg PO BID) PLUS a macrolide (azith 500mg day 1 followed by 250mg daily for 4 days or clarithromycin ER 1000mg daily or clarithromycin 500mg BID) OR levofloxacin 750mg daily or moxifloxacin 400mg PO daily

What are adverse effects of fluroquinolones?

1. Dyslgcemias

2. Altered Mental status

3. CNS side effects

4. Tendinitis / tendon rupture

5. QTc prolongation

6. C. difficile infection

What counseling point is important for patients taking fluroquinolones?

Avoid sunlight exposure

For what kind of patients should we monitoring BG closely that are taking flurooquinolones?

Patients with diabetes

What counseling points are important for macrolide?

1. avoid exposure to excessive sunlight & separate administration with antacids and multivitamins

What is the minimum duration of therapy for CAP?

Minimum of 5 days

What is the adult dosing for influenza?

Oseltamivir 75mg BID x days (first line agent) Preferred for hospitalized patients

What is influenza prophylaxis dosing?

oseltamivir - 75mg po daily

When should antiviral be initiated?

start within 48 hours of onset of symptoms; ideally started within 12 hours of symptoms

What is the recommendation for influenza vaccinations?

every 6 months and older

What is septic arthritis?

infection of the joint space

What is the most commonly seen etiology in septic arthritis?

S. aureus

What are risk factors of septic arthiritis?

1. Sexual exposure to Neisseria gonorrhoeae

2. Rheymatoid arthritis

3. Trauma

4. H/O septic arthritis

5. Joint punture or surgery (prophylactic abx are given cefazolin 1gm IV q8h x 24 hours)

6. IV drug abuse

What are subjective things of septic arthritis?

1. Painful swollen joint in the absence of trauma

2. Patients with gonococcal arthritis typically present with multiple inected joints (50% of cases)

What are objective things of septic arthritis?

1. fever

2. elevated ESR

3. Elevated C-reactive protein

4. Elevated WBC with left shift

5. Positive blood culure

How can you diagnosis septic arthritis?

1. Arthrocentesis - Synovial fluid culture via needle asipration

2. Blood culture

How do you manage septic arthritis?

1. IV antibiotics for 2 to 4 weeks

2. Joint drainage

3. Avoid use of joint during initial infection, range of motion can be increased after response to therapy

What is empiric therapy for broad spectrum?

1. vancomycin 15-20mg/kg IV every 8-12 hours; goal trough 15 to 20 mcg/ml

PLUS

2. ceftriaxone 1-2 grams every 12-24 hrs or

3. ceftazidime 1 gram IV every 8 hours or

4. cefepime 1 gram IV every 8 hours

If the patient has septic arthritis and the organism comes back as S. aureus (MSSA) what would you treat the patient with?

Nafcillin / oxacillin 2 gram IV q4h or cefazolin 1 gram IV q8h

If the patient has septic arthritis and the organism comes back as MRSA, what would you treat the patient with?

vancomycin, linezolid, clindamycin

If the patient has septic arthritis and the organism comes back as Streptococcus, what would you treat the patient with?

ceftriaxone 1gm IV q24h

If the patient has septic arthritis and the organsim comes back as gram negative rods, what would you treat the patient with?

ceftazidime 2 gm IV every 8 hours or cefepime 2 gm IV every 8 to 12 hours or piperacillin-tazobactam 4.5 gm IV every 6 hours

If the patient has septic arthritis and the organism comes back as pseudomonas, what would you treat the patient with?

ciprofloxacin 750mg PO BID or ceftazidime 2gm IV q8h plus tobramycin 5mg/kg/day

If the patient has septic arthritis and the organsim comes back as Neisseria gonorrheae (sexually active adults - suspect if culture negative) what would you treat the patient with?

ceftriaxone 1 gm IV q24h

What is osteomyelitis?

Infection of the bone

What are subjective signs of osteomyelitis?

1. tenderness / pain and swelling near affected area

2. decreased motion, malaise, chills

3. erythema can be found near site for contiguous osteomyelitis

What are objective signs of osteomyelitis?

1. Fever

2. elevated ESR

3. Elevated C-reactive protein

4. increased WBC & positive blood cultures

What are diagonisis of osteomyelitis?

1. Bone X-ray

2. Bone-scan

3. Bone aspiration

4. Blood culture

What are non-pharm treatments for osteomyelitis?

1. Surgery

2. Debridement of nectrotic tissue / bone

3. Hyperbariac oxygen

4. Removal of prosthesis (if present)

A 62-year-old man with diabetes presents with foot pain, swelling, erythema, and fever. He has a chronic ulcer on the plantar surface of his foot. ESR and CRP are elevated. X-ray is negative. What is the MOST appropriate next diagnostic step?

Bone scan

Which patient has the HIGHEST risk for contiguous osteomyelitis?

70 year old with a oristheti cknee and local joint swelling

Why is rapid diagnosis critical in osteomyelitis?

Prevents nectoric bone formation requiring surgery

A patient is started on empiric therapy for osteomyelitis. Why must MRSA be covered?

1/3 of cases are caused by MRSA

What is an appropriate empiric regimen for osteomyelitis?

Vancomycin and cefepime

A patient with osteomyelitis has a prosthetic hip. What is REQUIRED for cure?

Removal of the prosthesis

Which organism is MOST likely in a patient with sickle cell disease and osteomyelitis?

Psudomonas aeruginosa

Which finding is considered an OBJECTIVE sign of osteomyelitis?

Elevated ESR

Blood cultures in osteomyelitis are:

Positive about 50% of the time

Culture from bone aspiration grows MSSA. What is the BEST targeted therapy?

Nafcillin or cefazolin

Bone culture grows MRSA. Which is an appropriate targeted option?

Vancomycin, linezolid, or daptomycin

A patient's bone culture grows Pseudomonas. Which therapy is most appropriate?

Cefepime, meropenem or imipenem

What non-pharmacologic therapy is part of osteomyelitis management?

Hyperbaric oxygen

Why are long durations (4-6 weeks) of IV antibiotics required?

Bone has poor blood supply making infection hard to eradicate

What symptom would suggest contiguous rather than hematogenous osteomyelitis?

Erythema near an ulcer or wound site

A hospitalized patient with a PICC line develops fever and chills. Blood cultures are drawn. How should cultures be obtained?

2 sets of cultures (4 bottles total)

During treatment of bacteremia, blood cultures should be repeated:

every 2 to 4 days until negative

A patient with bacteremia is suspected of having endocarditis. What diagnostic test is indicated?

TTE or TEE

What is the most common cause of bacteremia

S. aureus

What is bactermia

infection in the blood stream

What are examples of risk factors for bactermia?

1. Corticosteriods

2. IVDU

3. Parenteral nutrition

4. Immuosuppressing medications

What is the typical IV antibiotic treatment for bactermia?

7 to 14 days, some require longer treatment up to 6 weeks

What are some empiric therapy that may consist of bactermia?

Vancomycin plus either cefepime, a carbapenem or piperacillin / tazobactam

If a patient has bactermia, and the culture comes back with MRSA what is the treatment?

vancomycin 15 to 20mg/kg IV every 12 hours

If a patient has bactermia, and the culture comes back with MSSA what is the treatment?

oxacillin or nafcillin 2g IV every 4 hours or cefazolin 2 g IV every 8 hours

What is the most common etiology for endocarditis?

Gram postive organisms (Staphylococcus, Virdans streptococcus, Streptococcus gallolyticus and enterococcus)

What are clincial presentation of endocarditis?

1. Fever is common (90% of cases)

2. Chills, weakness, malaise

3. HF

4. Embolic phenomena - splinter hemmorrhages, Janeway lesiosn

5. Roth spots, Osler nodes

6. Elevated ESR, CRP, rheumaotid factor

What is infective endocarditis?

An infection on the endocardial surface of the heart. The infection typically inculdes one or more heart valves. When heart valves are involved- a vegetation can be seen on imaging

Native Valve Endocarditis (NVE)

endocarditis occuring on ones own valve

Prosthetic Valve Endocarditis (PVE)

occurs on a surgically implanted valve which can be tissue or mechanical

What are risk factors of endocarditis?

1. Poor dental hygiene

2. Dialysis, long term

3. Diabetes

4. HIV

5. Prosthetic Valve

A patient is receiving Vancomycin 1.25g IV every 12 hours for a skin and soft tissue infection. A steady-state trough is drawn correctly and returns at 12.5 mg/L. The clinical team wants to target a trough of 17.5 mg/L. Using linear kinetics principles, what should the new total daily dose be?

3.5 gram total daily dose

How should you think of ID?

bug, drug, patient connection

What is empiric therapy?

When an organism has not been isolated at the time of prescirbing